1. Hematological System Medications
Diane McLean RN MSN
Nursing 202

2. Various Drugs Anticoagulants
Inhibit the action or formation of clotting factors
Prevent clot formation
Antiplatelet drugs
Inhibit platelet aggregation
Prevent platelet plugs
Thrombolytic drugs
Lyse (break down) existing clots
Hemostatic or Antifibrinolytic drugs
Promote blood coagulation

3. Hemostasis
The process that halts bleeding after injury to a blood vessel
Complex relationship between substances that promote clot formation and either inhibit coagulation or dissolve a formed clot

4. Anticoagulants
Have no direct effect on a blood clot that is already formed
Used prophylactically to prevent
Clot formation (thrombus)
An embolus (dislodged clot)

5. Coagulation System “Cascade”
Each activated factor serves as a catalyst that amplifies the next reaction
Result is fibrin, a clot-forming substance
Intrinsic pathway and extrinsic pathway

6. Anticoagulants: Mechanism of Action
Vary, depending on drug
Work on different points of the clotting cascade
Do not lyse existing clots
heparin and low-molecular-weight heparins
Turn off coagulation pathway and prevent clot formation
warfarin

7. Anticoagulants: Mechanism of Action…
All ultimately prevent clot formation
heparin
Low-molecular-weight heparins
warfarin (Coumadin)

8. Anticoagulants Prevention of clot formation also prevents: Stroke
Myocardial infarction (MI)
Deep vein thrombosis (DVT)
Pulmonary embolism (PE)

9. Anticoagulants: Indications
Used to prevent clot formation in certain settings where clot formation is likely
Myocardial infarction
Unstable angina
Atrial fibrillation
Indwelling devices, such as mechanical heart valves
Major orthopedic surgery

10. Anticoagulants: Adverse Effects
Bleeding
Risk increases with increased dosages
May be localized or systemic
May also cause:
Nausea, vomiting, abdominal cramps, thrombocytopenia, others

11. Anticoagulants heparin
Monitored by activated partial thromboplastin times (aPTTs)
Parenteral
Short half-life (1 to 2 hours)
Effects reversed by protamine sulfate
Obtained from sheep, cows, and pigs

12. Anticoagulants… Low-molecular-weight heparins
enoxaparin (Lovenox) and dalteparin (Fragmin)
More predictable anticoagulant response
Do not require frequent laboratory monitoring
Given subcutaneously

13. Anticoagulants … warfarin sodium (Coumadin) Given orally only
Monitored by prothrombin time (PT) and INR (PT-INR)
Vitamin K can be given if toxicity occurs
Herbals potential interactions
Feverfew
Garlic
Ginger
Ginkgo
ginseng

14. Antiplatelet Drugs Prevent platelet adhesion Aspirin
dipyridamole (Persantine)
clopidogrel (Plavix) and ticlopidine (Ticlid)
ADP inhibitors
tirofiban (Aggrastat), eptifibatide (Integrilin)
New class, GP IIb/IIIa inhibitors

15. Antiplatelet Drugs… Indications Antithrombotic effects
Reduce risk of fatal and nonfatal strokes
Adverse effects
Vary according to drug

16. Antifibrinolytic Drugs
Prevent the lysis of fibrin
Results: promote clot formation
Used for prevention and treatment of excessive bleeding resulting from hyperfibrinolysis or surgical complications

17. Antifibrinolytic Drugs…
aminocaproic acid (Amicar)
desmopressin (DDAVP)
Similar to ADH
Also used in the treatment of diabetes insipidus

18. Antifibrinolytic Drugs: Indications
Prevention and treatment of excessive bleeding
Hyperfibrinolysis
Surgical complications
Excessive oozing from surgical sites such as chest tubes
Reducing total blood loss and duration of bleeding in the postoperative period

19. Antifibrinolytic Drugs: Adverse Effects
Uncommon and mild
Rare reports of thrombotic events
Others include:
Dysrhythmia, orthostatic hypotension, bradycardia, headache, dizziness, fatigue, nausea, vomiting, abdominal cramps, diarrhea, others

20. Thrombolytic Drugs Drugs that break down, or lyse, preformed clots
Older drugs
streptokinase and urokinase
Newer drugs
Tissue plasminogen activator
Anisoylated plasminogen-streptokinase activator complex (APSAC)

21. Thrombolytic Drugs… streptokinase (Streptase) anistreplase (Eminase)
alteplase (t-PA, Activase)
reteplase (Retavase)
tenecteplase (TNKase)
drotrecogin alfa (Xigris)

22. Thrombolytic Drugs: Mechanism of Action
Activate the fibrinolytic system to break down the clot in the blood vessel quickly
Activate plasminogen and convert it to plasmin, which can digest fibrin
Reestablish blood flow to the heart muscle via coronary arteries, preventing tissue destruction

23. Thrombolytic Drugs: Indications
Acute MI
Arterial thrombolysis
DVT
Occlusion of shunts or catheters
Pulmonary embolus
Acute ischemic stroke

24. Thrombolytic Drugs: Adverse Effects
BLEEDING
Internal
Intracranial
Superficial
Other effects
Nausea, vomiting, hypotension, anaphylactoid reactions
Cardiac dysrhythmias

25. Nursing Implications Assess:
Patient history, medication history, allergies
Contraindications
Baseline vital signs, laboratory values
Potential drug interactions—there are MANY!
History of abnormal bleeding conditions

26. Heparin: Nursing Implications
Intravenous doses are usually double checked with another nurse
Ensure that SC doses are given SC, not IM
½ to 5/8” 25 to 28 gauge needle
SC doses should be given in areas of deep subcutaneous fat, and sites rotated

27. Heparin: Nursing Implications …
Do not give SC doses within 2 inches of:
The umbilicus, abdominal incisions, or open wounds, scars, drainage tubes, stomas
Do not aspirate SC injections or massage injection site
May cause hematoma formation

28. Heparin: Nursing Implications…
IV doses may be given by bolus or IV infusions
Anticoagulant effects seen immediately
Laboratory values are done daily to monitor coagulation effects (aPTT)
Protamine sulfate can be given as an antidote in case of excessive anticoagulation
1mg = 1mg

29. LWMHs: Nursing Implications
Given subcutaneously in the abdomen
Rotate injection sites
Protamine sulfate can be given as an antidote in case of excessive anticoagulation

30. Warfarin Sodium: Nursing Implications
May be started while the patient is still on heparin until PT-INR levels indicate adequate anticoagulation
Full therapeutic effect takes several days
Monitor PT-INR regularly—keep follow-up appointments
Antidote is vitamin K

31. Warfarin: Nursing Implications
Many herbal products have potential interactions—increased bleeding may occur
Capsicum pepper
Garlic
Ginger
Gingko
Ginseng
Feverfew

32. Anticoagulants: Patient Education
Education should include:
Importance of regular lab testing
Signs of abnormal bleeding
Measures to prevent bruising, bleeding, or tissue injury

33. Anticoagulants: Patient Education…
Education should include (cont'd):
Wearing a medical alert bracelet
Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables)
Consulting physician before taking other meds or OTC products, including herbals

34. Antiplatelet Drugs: Nursing Implications
Concerns and teaching tips same as for
anticoagulants
Dipyridamole should be taken on an empty stomach
Drug-drug interactions
Adverse reactions to report
Monitoring for abnormal bleeding

35. Thrombolytic Drugs: Nursing Implications
Follow strict manufacturer’s guidelines for preparation and administration
Monitor IV sites for bleeding, redness, pain
Monitor for bleeding from gums, mucous membranes, nose, injection sites
Observe for signs of internal bleeding (decreased BP, restlessness, increased pulse

36. Coagulation Modifier Drugs Nursing Implications
Monitor for therapeutic effects
Monitor for signs of excessive bleeding
Bleeding of gums while brushing teeth, unexplained nosebleeds, heavier menstrual bleeding, bloody or tarry stools, bloody urine or sputum, abdominal pain, vomiting blood

37. Coagulation Modifier Drugs Nursing Implications …
Monitor for adverse effects
Increased BP, headache, hematoma formation, hemorrhage, shortness of breath, chills, fever

38. Iron Essential mineral in the body
Oxygen carrier in hemoglobin and myoglobin
Stored in the liver, spleen, bone marrow
Iron deficiency results in anemia

39. Iron … Dietary sources: meats, certain vegetables and grains
Dietary iron must be converted by gastric juices before it can be absorbed

40. Iron … Some foods enhance iron absorption
Orange juice, veal, fish, ascorbic acid
Some foods impair iron absorption
Eggs,* corn, beans,* cereal products containing phytates
*Eggs and beans are also common dietary sources of iron

41. Iron …
Supplemental iron may be given as a single drug or as part of a multivitamin preparation
Contradindicated with Hemolytic anemia
Oral iron preparations are available as ferrous salts
Ferrous fumarate, ferrous gluconate, ferrous sulfate
Parenteral form: iron dextran
Give with normal saline not 5% dextrose

42. Iron: Indications
Prevention and treatment of iron-deficiency syndromes
Administration of iron alleviates the symptoms of iron-deficiency anemia, but the underlying cause of the anemia should be corrected
4 week (absence of fatique)

43. Iron: Adverse Effects
Nausea, vomiting, diarrhea, constipation, stomach cramps, and pain
Causes black, tarry stools
Liquid oral preparations may stain teeth
Injectable forms may stain skin and cause pain upon injection
Avoid reclining position for 15 to 30 minutes-avoid esophageal irritation or corrosion
Antacids/milk decrease absorption
Whole/not crushed
Take with food to help reduce GI distress but it also may decrease absorption

44. Iron Dextran Parenteral use (IM or IV)
Z-track method, deep into a large muscle mass
May cause anaphylactic reactions, including fatal anaphylaxis
Test dose usually given, then remainder of dose after 1 hour

45. Folic Acid Water soluble, B-complex vitamin
Essential for erythropoiesis
Primarily used to prevent and treat folic acid deficiency
Malabsorption syndromes are the most common cause of deficiency

46. Folic Acid …
Should not be used until actual cause of anemia is determined
May mask symptoms of pernicious anemia, which requires treatment other than folic acid
Untreated pernicious anemia progresses to neurologic damage

47. Folic Acid: Indications
Folic acid deficiency anemia
Tropical sprue
Prenatal prophylaxis of neural tube defects

48. Other Blood-Forming Drugs
cyanocobalamin (vitamin B12)
erythropoietin (Epogen, Procrit

49. Nursing Implications
Assess patient history, medication history, including drug allergies
Assess for potential contraindications
Assess baseline laboratory values, especially Hgb, Hct, reticulocytes, others
Obtain nutritional assessment

50. Nursing Implications…
Ferrous salts are contraindicated in patients with ulcerative colitis, PUD, liver disease, other GI disorders
Iron dextran is contraindicated in all anemias except for iron-deficiency anemia

51. Nursing Implications …
For liquid iron preparations, follow manufacturer’s guidelines on dilution and administration
Instruct patient to take liquid iron preparations through a straw to avoid staining tooth enamel

52. Nursing Implications …
Oral forms of iron should be taken between meals for maximum absorption, but may be taken with meals if GI distress occurs
Oral forms should be given with juice, but not with milk or antacids

53. Nursing Implications …
Patients should remain upright for 15 to 30 minutes after oral iron doses to avoid esophageal corrosion
Patients should be encouraged to eat foods high in iron/folic acid

54. Nursing Implications …
For iron dextran, a small test dose should be given
After 1 hour, if no reaction, the remainder of the dose can be given
Administer deeply into a large muscle mass using the Z-track method

55. Nursing Implications …
For IV doses of iron dextran, give carefully according to manufacturer’s instructions
Have resuscitative equipment available in case of anaphylactic reaction

56. Nursing Implications …
Determine cause of anemia before administering folic acid
Oral folic acid should be given with food
Folic acid may also be given IV and added to total parenteral nutrition solutions

57. Nursing Implications …
Monitor for therapeutic responses
Improved nutritional status
Increased weight, activity tolerance, well-being
Absence of fatigue
Monitor for adverse effects

58. Medications to Know Coumadin Neupogen (filgrastim)
Persantine Rituxen (rituximab)
Iron Dextran Filgrastin
Oral Iron Epogen (procrit)
Folic Acid Activase (alteplase)
Cyanobalamin Trental
Oprelvekin Lovenox
Lovenox Fragmin
Heparin ASA
Indications & expected outcomes; nursing interventions,
Patient teaching, labs, antidotes/dosages, etc.